The Lodge

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question Good. At this assessment the rating has changed to Requires Improvement.

This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The service was in breach of Regulation 17 (Good Governance) due to failures in oversight, monitoring and the provider’s governance systems.

This service scored 54 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider did not have a clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not always understand the challenges and the needs of people and their communities.

Some people did not have their social or emotional needs met and told us they experienced isolation at the service. This meant people were at risk of harm and becoming withdrawn by not receiving person centred care to prevent isolation. This had not been identified and addressed by the staff team to ensure people received the care and support they required.

Although the provider took some action in response to issues identified during our first visit, these shortfalls had not been identified by the provider’s own systems or by staff. This demonstrated gaps in oversight and in staff awareness of when improvements were needed. It also showed the culture within the service did not always support staff to recognise and escalate concerns, or to reflect on practice in a way that drives improvement.

Leaders did understand the context in which the provider delivered care, treatment and support. However, they did not always embody the culture and values of their workforce and organisation. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively, or they did not always do so with integrity, openness and honesty.

The context in which the provider delivered care did not always result in positive experiences for everyone living at the service. Although leaders had a detailed knowledge of people’s individual needs and were able to talk confidently about them, this understanding was not consistently translated into day‑to‑day practice. For example, some people told us they felt isolated, and not all individuals were supported to take part in activities that could help them stay connected and engaged. A person told us that they ‘Would like a visiting do and be told more about what was going on.’ We observed People being left unsupervised with minimal interaction. A visiting professional said they felt People using the service ‘Require more engagement.’ While people were able to access the garden, opportunities to support social contact and reduce loneliness were not always used effectively. As a result, people did not always experience care that felt inclusive, or that promoted their emotional wellbeing.

We received mixed views from people and relatives regarding the management in the service, some told us the management team were approachable and listened to and acted on any concerns they had. However, a relative said they were not assured that the staff were open and honest with them regarding the care and wellbeing of their family member.

People did not always feel they could speak up and that their voice would be heard. Staff told us they would report concerns to the management team and felt they would be listened to; however, they were not always clear about who to escalate concerns to outside the service if their worries were not addressed internally. This demonstrated that staff lacked confidence and clarity about external reporting routes, such as how to contact the local safeguarding team or other agencies. As a result, there was a risk of closed cultures developing and a risk that serious concerns may not be raised promptly or through the correct channels if staff felt internal responses were insufficient.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

Staff told us they were happy working in the service, and they felt supported by the management team.

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

We noted shortfalls which had not been independently identified and/or addressed by the provider prior to our assessment. This included one person’s records not including any end-of-life decisions, and another person’s records did not include a wound care plan to guide staff despite the person having skin integrity concerns. Therefore, staff did not have the essential information they needed to provide consistent, safe care, increasing the risk of people receiving support that did not reflect their wishes, was not delivered in a timely way, or failed to prevent avoidable deterioration in their health.

Health and safety risks had not been addressed by the provider when we visited, this included an unsecured wardrobe, exposed radiator and pipes, and malodour in a person’s bedroom.

We fed back our findings to the management team, and they had confirmed the actions they had and were taking to address them. However, we were concerned the provider’s own monitoring and auditing systems had failed to independently identify and/or address all of these issues and the potential immediate risks, prior to them being pointed out by external professionals. This also included a lack of equipment to ensure people’s privacy when they resided in a shared bedroom.

The provider did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people. They did not always share information and learning with partners or collaborate for improvement.

Visiting professionals told us the management team were receptive to suggestions to improve the service, including plans to receive support for staff sessions on the care provision. A health professional told us they had monthly meetings with the management team to ensure any risks were discussed. However, we received information that the provider was not always informing the local authority of incidents. This was a concern because failing to share key information with statutory partners meant important safeguarding and contractual oversight could be delayed, reducing the effectiveness of joint working and increasing the risk that significant issues were not identified or acted upon in a timely way.

The provider did not always focus on continuous learning, improvement or innovation within the service. They did not consistently promote approaches that improved people’s experiences, outcomes or quality of life. Systems intended to monitor care quality and safety were not effective in helping the provider or management team identify where improvements were required. We found the current oversight processes did not alert leaders to important shortfalls in areas such as care planning, record keeping and environmental safety. Because these issues had not been recognised or addressed before our assessment, this did not demonstrate a service that was learning, adapting or driving ongoing improvement.